Computerized Occlusion Rating: A Superior Predictor of Aneurysm Rebleeding for Ruptured Embolized Aneurysms

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Fig 1.
Computerized occlusion rating. A and D, Overview of the 2 selected projections. B and E, Definition of the total aneurysm area (red line), false-color-labeled contrast medium flow (yellow) (C and F), and nonoccluded area within the aneurysm (yellow) (F). This is a typical example demonstrating the need for precise image selection. Solely evaluating the first projection would result in 100% occlusion. As in the first projection (A–C), the occluded part of the aneurysm sac projects over the nonoccluded areas and hides them. A small rotation of the first projection then shows nonoccluded areas at the neck and in the aneurysm sac (D and F).
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Fig 2.
Kaplan-Meier survival curves of aneurysm rerupture according to COR (A) and SOR (B).

Table 1:

Characteristics of the patients

	Stable Aneurysms (n = 242)	Reruptured Aneurysms (n = 7)	P^a
Mean age (yr)	60 (±12)	63 (±13)	NS
Female sex (No.)	170	6	NS
Baseline parameters
Fisher grading (1–4) (No.)	22, 44, 98, 78	0, 2, 3, 2	NS
Hunt and Hess grading (1–5) (No.)	48, 39, 59, 82, 14	1, 1, 2, 2, 1	NS
Aneurysm location (No.)			NS
Anterior cerebral artery	78	1
Internal carotid artery	62	2
Medial cerebral artery	6	0
Posterior communicating artery	24	1
Basilar artery	60	3
Other posterior circulation	9	0
Aneurysm morphology
Size (<5 mm, 5–10 mm, >10 mm) (No.)	58, 125, 59	1, 4, 2	NS
(mean value)	(8.11 ± 3.82)	(7.34 ± 2.00)
Neck (<4 mm, >4 mm) (No.)	177, 65	3, 4	.0382
(mean value)	(3.19 ± 1.51)	(4.26 ± 0 · 77)
Aspect ratio (mean value)	2.65 ± 1.21	1.7 ± 0.19	<.0001
Nonoccluded area (mm²) (mean value)	9.41 ± 1.89	8,95 ± 9,94	NS
Total area (mm²) (mean value)	49.23 ± 48.01	46.41 ± 29.84	NS
Follow-up
GOS (1–5) (No.)	26, 42, 24, 41, 109	2, 1, 2, 1, 1, 1	NS

Note:—No. indicates number of patients.
↵a P values derived from the paired t test for continuous variables and the Kruskal-Wallis test for categoric variables.

Table 2:

Characteristics of patients with aneurysm rerupture

Sex	Age (yr)	Re-Rupture (days)	Fisher Grade	HH Grade	Location	SOR (%)	COR (%)	Aneurysm Neck Width (mm)	Aneurysm Length (mm)	Total Area (mm²)	Nonoccluded Area (mm²)	Final GOS
F	44	1	4	3	ICA	80/80	71.9/73.4	4.5/4.7	7.0/7.3	38.5/39.4	10.8/10.4	2
F	56	185	3	2	ICA	90/95	87.2/84.9	3.8/3.5	6.5/6.2	22.0/23.2	2.8/3.5	3
F	73	1	4	4	ACA	95/95	85.1/88.3	3.5/3.4	5.3/5.1	18.3/20.8	2.7/2.4	1
F	55	4	3	4	Bas	90/95	89.6/88.2	5.7/5.5	10.1/10.5	91.5/89.8	9.5/10.5	1
M	83	10	4	3	Bas	100/95	94.6/93.9	4.1/4.2	7.3/7.2	38.4/40.1	2.1/2.4	4
F	76	5	3	5	Bas	70/80	67.2/64.6	4.8/5.1	10.1/10.2	95.7/91.1	31.4/32.3	3
F	58	20	2	1	PcomA	90/95	88.1/89.3	3.4/3.4	5.1/4.8	21.1/19.8	2.5/2.1	5

Note:—HH indicates Hunt and Hess; ACA, anterior cerebral artery; Bas, basilar artery; PcomA, posterior communicating artery.

Table 3:

Literature overview of important recent studies on aneurysm rerupture of embolized ruptured cerebral aneurysms

	Patients		Aneurysm Occlusion Raymond Classes (%) 1–3 (<70%)	Reruptured
	No.	FU (mo)	Aneurysm Occlusion Raymond Classes (%) 1–3 (<70%)	Overall (%)	Raymond Classes (%) 1–3 (<70%)
Johnston et al, 2008 (CARAT)³	1001	48	75.9/17.3/5.1/(1.7)	1.9 (n = 19)	1.1/2.9/5.9/(17.6)	S
Molyneux et al, 2005, 2009 (ISAT) (late rebleeding)^1,2	1096 (881)^a	60	66/26/8 (11% without DSA)	1.1 (n = 10)	0.5/1.7/4.3	ND^a
Jartti et al, 2010 (early rebleeding)¹³	194	1	31.5/51/27.5	3.6 (n = 7)	[2.5]/8.8	NS^b
Sluzewski et al, 2005 (late rebleeding)¹⁵	393	47.7	[93.2]/6.8^b	1.1 (n = 4)	[0.8]/7.4	S^b
Sluzweski and van Rooij, 2005 (early rebleeding)¹⁶	431	1	ND	1.4 (n = 6)	ND	S^c
Plowman et al, 2010 (late rebleeding)¹⁷	570	73.7	62.5/32.1/5.6	1.1 (n = 6)	0.9/4.6/0	NS
Renowden et al, 2009¹⁸	711	17	62.5/33/5.0	1.7 (n = 12)	[1.5]/2.7	ND^b
Willinsky et al, 2009¹⁹	377	22.3	43/36/20	2.1 (n = 8)	1.1/2.8/2.5	NS
Kang et al, 2010²⁰	797	ND	74.2/[25.8]^d	1.0 (n = 8)	1.0/[1.0]	ND^d
Piotin et al, 2009²²	74	14	50.9/23/26.1	1.3 (n = 1)	ND	ND
Choi et al, 2010²¹	91	34.4	100/0/0	0	0	ND
Sherif and Plenk, 2011⁷	249	59	SOR, 28.1/59.8/11.1;	2.8% (n = 7)	SOR, 0/3.4/7.3	NS
			COR, 6.5/49.9/41.4/(2.1)		COR, 0/0.7/5.2/(16.7)	S

Note:—FU indicates follow-up time, for all citations: only rebleeding of treated aneurysms; S, significant; NS, not significant; ND, no data available; ISAT, International Subarachnoid Aneurysm Trial.
↵a Patients with angiograms, rebleedings related to patients with available angiograms (data provided by Dr Molyneux).
↵b Raymond Class 1 + 2 pooled.
↵c In univariate logistic regression.
↵d Class 2 + 3 pooled.